P - 36958-�19�----
Building MECHAI�+IIC:AL Permit No.:
Inspections RESIDENTIAL AP�'LICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: l�' l�
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE YOUR E-MAIL ADDRESS Krn�a � marsh h Q,�� G,CO%�
SITE ADDRESS '1� I /�I T S i�✓I ��.
THiS APPLICANT IS: ❑ OWNER �]20NTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME: �`1,(5 V_�i V't" 1( � j G.+
ADDRESS: ZD ( kGVI Vl t V� �
PHONE: 7/$?j �' (QO ^T " �� l �
COMPANY NAME:
CONTACT PERSON:
�
CI7Y �r'ic�I��/w STA
STATE LICENSE # EXP DAT'E ���('
ADARESS:J,p��� C� �Gi /Q�/'C /1! CITY�Y'�Gi✓i Y'/CY�.'-STATE/rAtiLIP_
r�
PHONE 71�!3 - ,�'.i� � O(/�o'i FAX �%�j �j ` !'S' ?j(� ' ��•� (i
ETSINGLE FAMILY ❑ TWO FAMILY
❑ NEW �PLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
O ALTERAT[ON/REMODEL
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WAERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: l� �n rlaC MODEL: (��Q �C"N �i4�AO%(� SIZE/BN %� t%�1�
MFG: MODEL: SIZFJBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGElOVEN $10.00
AIRTO AIREXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 _FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY LINER $]0.00 _GA5 DRYER $10.00 POOL HEATER $35:00
_DUCT WORK $10.00 _GAS PIPING $10.00 VENTILAT'OR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that �e work will be in accordance with the
approved plan in the case of all work which requires revieyy and approval of plans. .,
SIGNATURE OF APPLICANT
APPROVAL
DA
City of Fridley
�uilding Inspections Department
6431 University Avenue NE, Frid(ey, MN 55432
763-572-3604 FAX: 763-502-4977
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